The death toll in Puerto Rico from Hurricane Maria’s devastation far exceeds previously reported numbers: According to a new study, more than 4,600 people are estimated to have died on the island, many from delayed medical care. The government’s initial tally was 64 deaths, which many in the medical community have long suspected to be a dramatic undercount. Puerto Rico is still struggling with rebuilding from the massive storm, including contending with continued power cuts, as hurricane season approaches again.

Researchers from Harvard’s T.H. Chan School of Public Health and other institutions published in the New England Journal of Medicine that the numbers they put forward are still imprecise and may be under the true death toll—but they found a 62 percent increase in Puerto Rico’s mortality rate in the three months after the storm, versus the same period in 2016. Their methodology reflects the difficulties in reporting the fallout from the hurricane beyond its initial impact on the island. Of the Puerto Ricans interviewed for the study, many reported losing loved ones as a result of interrupted medical care due to loss of power and lack of access to medical necessities after the storm. The respondents were asked about “displacement, infrastructure loss, and causes of death.”

Donald Trump notoriously bragged about the supposedly low death toll at the time, comparing the number to that of Hurricane Katrina (“a real catastrophe”) and asking the Puero Rico governor, “What is your death count, as of this moment—17?” He also seemed to jokingly blame Puerto Ricans for the drain on American resources (though exactly how much of a drain is clearly in question, given the island’s continued struggles): “Now, I hate to tell you, Puerto Rico, but you’ve thrown our budget a little out of whack because we’ve spent a lot of money on Puerto Rico, and that’s fine. We’ve saved a lot of lives.” Then there was his treatment of San Juan Mayor Carmen Yulín Cruz, whom he called “nasty.” All of which is to say that when Trump tweets things about how great America is (like this Memorial Day, for example, when he crowed over “how well our country is doing today,” including the “lowest unemployment numbers for Blacks and Hispanics EVER”), he isn’t even considering the humanitarian crisis in Puerto Rico.